CIGNA High Deductible Health Plan (HDHP) - UCAR Finance ...

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• inpatient services at any participating Other Health Care Facility; • residential treatment; • outpatient facility services; • advanced radiological imaging; • non-emergency ambulance; or • transplant services. HC-PRA1 04-10 V1 Covered Expenses The term Covered Expenses means the expenses incurred by or on behalf of a person for the charges listed below if they are incurred after he becomes insured for these benefits. Expenses incurred for such charges are considered Covered Expenses to the extent that the services or supplies provided are recommended by a Physician, and are Medically Necessary for the care and treatment of an Injury or a Sickness, as determined by CIGNA. Any applicable Copayments, Deductibles or limits are shown in The Schedule. Covered Expenses • charges made by a Hospital, on its own behalf, for Bed and Board and other Necessary Services and Supplies; except that for any day of Hospital Confinement, Covered Expenses will not include that portion of charges for Bed and Board which is more than the Bed and Board Limit shown in The Schedule. • charges for licensed ambulance service to or from the nearest Hospital where the needed medical care and treatment can be provided. • charges made by a Hospital, on its own behalf, for medical care and treatment received as an outpatient. • charges made by a Free-Standing Surgical Facility, on its own behalf for medical care and treatment. • charges made on its own behalf, by an Other Health Care Facility, including a Skilled Nursing Facility, a Rehabilitation Hospital or a subacute facility for medical care and treatment; except that for any day of Other Health Care Facility confinement, Covered Expenses will not include that portion of charges which are in excess of the Other Health Care Facility Daily Limit shown in The Schedule. • charges made for Emergency Services and Urgent Care. • charges made by a Physician or a Psychologist for professional services. • charges made by a Nurse, other than a member of your family or your Dependent’s family, for professional nursing service. • charges made for anesthetics and their administration; diagnostic x-ray and laboratory examinations; x-ray, radium, and radioactive isotope treatment; chemotherapy; blood transfusions; oxygen and other gases and their administration. • charges made for an annual prostate-specific antigen test (PSA). • charges made for laboratory services, radiation therapy and other diagnostic and therapeutic radiological procedures. • charges made for Family Planning, including medical history, physical exam, related laboratory tests, medical supervision in accordance with generally accepted medical practices, other medical services, information and counseling on contraception, implanted/injected contraceptives, after appropriate counseling, medical services connected with surgical therapies (tubal ligations, vasectomies). • charges made for the following preventive care services (detailed information is available at www.healthcare.gov/center/regulations/prevention/recomm endations.html): (1) evidence-based items or services that have in effect a rating of “A” or “B” in the current recommendations of the United States Preventive Services Task Force; (2) immunizations that have in effect a recommendation from the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention with respect to the Covered Person involved; (3) for infants, children, and adolescents, evidenceinformed preventive care and screenings provided for in the comprehensive guidelines supported by the Health Resources and Services Administration; (4) for women, such additional preventive care and screenings not described in paragraph (1) as provided for in comprehensive guidelines supported by the Health Resources and Services Administration. • charges made for surgical or nonsurgical treatment of Temporomandibular Joint Dysfunction. • charges made for acupuncture. • charges made for hearing aids, including but not limited to semi-implantable hearing devices, audiant bone conductors and Bone Anchored Hearing Aids (BAHAs). A hearing aid is any device that amplifies sound. 22 myCIGNA.com
Clinical Trials Charges made for routine patient services associated with cancer clinical trials approved and sponsored by the federal government. In addition the following criteria must be met: • the cancer clinical trial is listed on the NIH web site www.clinicaltrials.gov as being sponsored by the federal government; • the trial investigates a treatment for terminal cancer and: the person has failed standard therapies for the disease; cannot tolerate standard therapies for the disease; or no effective nonexperimental treatment for the disease exists; • the person meets all inclusion criteria for the clinical trial and is not treated “off-protocol”; • the trial is approved by the Institutional Review Board of the institution administering the treatment; and • coverage will not be extended to clinical trials conducted at nonparticipating facilities if a person is eligible to participate in a covered clinical trial from a Participating Provider. Routine patient services do not include, and reimbursement will not be provided for: • the investigational service or supply itself; • services or supplies listed herein as Exclusions; • services or supplies related to data collection for the clinical trial (i.e., protocol-induced costs); • services or supplies which, in the absence of private health care coverage, are provided by a clinical trial sponsor or other party (e.g., device, drug, item or service supplied by manufacturer and not yet FDA approved) without charge to the trial participant. Genetic Testing Charges made for genetic testing that uses a proven testing method for the identification of genetically-linked inheritable disease. Genetic testing is covered only if: • a person has symptoms or signs of a genetically-linked inheritable disease; • it has been determined that a person is at risk for carrier status as supported by existing peer-reviewed, evidencebased, scientific literature for the development of a genetically-linked inheritable disease when the results will impact clinical outcome; or • the therapeutic purpose is to identify specific genetic mutation that has been demonstrated in the existing peerreviewed, evidence-based, scientific literature to directly impact treatment options. Pre-implantation genetic testing, genetic diagnosis prior to embryo transfer, is covered when either parent has an inherited disease or is a documented carrier of a geneticallylinked inheritable disease. Genetic counseling is covered if a person is undergoing approved genetic testing, or if a person has an inherited disease and is a potential candidate for genetic testing. Genetic counseling is limited to 3 visits per contract year for both preand post-genetic testing. Nutritional Evaluation Charges made for nutritional evaluation and counseling when diet is a part of the medical management of a documented organic disease. Internal Prosthetic/Medical Appliances Charges made for internal prosthetic/medical appliances that provide permanent or temporary internal functional supports for nonfunctional body parts are covered. Medically Necessary repair, maintenance or replacement of a covered appliance is also covered. HC-COV1 04-10 Orthognathic Surgery • orthognathic surgery to repair or correct a severe facial deformity or disfigurement that orthodontics alone can not correct, provided: • the deformity or disfigurement is accompanied by a documented clinically significant functional impairment, and there is a reasonable expectation that the procedure will result in meaningful functional improvement; or • the orthognathic surgery is Medically Necessary as a result of tumor, trauma, disease or; • the orthognathic surgery is performed prior to age 19 and is required as a result of severe congenital facial deformity or congenital condition. Repeat or subsequent orthognathic surgeries for the same condition are covered only when the previous orthognathic surgery met the above requirements, and there is a high probability of significant additional improvement as determined by the utilization review Physician. HC-COV3 04-10 Home Health Care Services • charges made for Home Health Care Services when you: • require skilled care; V3 V1 23 myCIGNA.com
Page 1: University Corporation for Atmosphe
Page 4 and 5: Women’s Health and Cancer Rights
Page 6 and 7: Explanation of Terms You will find
Page 8 and 9: provided by other parties to the Po
Page 10 and 11: In addition, if at any time a Prima
Page 12 and 13: Assistant Surgeon and Co-Surgeon Ch
Page 14 and 15: BENEFIT HIGHLIGHTS IN-NETWORK OUT-O
Page 24 and 25: • are unable to obtain the requir
Page 26 and 27: • counseling for occupational pro
Page 28 and 29: covered subject to the following co
Page 30 and 31: Prescription Drug Benefits For You
Page 32 and 33: • treatment of an Injury or Sickn
Page 34 and 35: Coordination of Benefits This secti
Page 36 and 37: Medicare Eligibles CIGNA will pay a
Page 38 and 39: Recovery of Overpayment When an ove
Page 40 and 41: in the Plan. You must request enrol
Page 42 and 43: If a child placed for adoption is n
Page 44 and 45: of the request. If more time is nee
Page 46 and 47: advance of the Committee’s decisi
Page 48 and 49: Medicare (Part A, Part B or both) w
Page 50 and 51: Trade Act of 2002 The Trade Act of
Page 52 and 53: In addition, if you disagree with t
Page 54 and 55: Employee The term Employee means a
Page 56 and 57: • rendered in the least intensive
Page 58 and 59: for injectables covered under the p
Page 60 and 61: What You Should Know about CIGNA Ch
Page 62: once to better understand side effe

CIGNA High Deductible Health Plan (HDHP) - UCAR Finance ...

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